Global Innovations in Patient-Centered Kidney Care

Disrupting Disease Progress: Mobilizing the People to Prevent Kidney Disease Progress Barry H. Smith MD, PhD The Rogosin Institute May 22, 2019 Disclosures:

Barry H. Smith MD, PhD President/CEO The Rogosin Institute NONE Background:

Current State of the U.S. Healthcare System The Cost of U.S. Health Care

The U.S. Example: U.S. spent 17.8% of GDP on its healthcare in 2015; 19.9% in 2025 Suboptimal Outcomes Shorter and Decreasing Life Expectancy

U.S. #53 @79.25 (now 78.6) yrs; 68 yrs. in Brownsville, Brooklyn Monaco #[email protected]; Japan #[email protected] Healthcare Spending as % GDP Worldwide

Japan: less than 0.5 of US health spending in 2014 with 7 years more life expectancy (85 vs 78) U.S. Life Expectancy Healthcare System Failure!!!!

Medicare “bankruptcy” by 2024? Social Security failure by 2033? (75% of todays’ benefits to be paid by 2033) U.S. Health Care

Chronic illness as a big and growing problem. The Impetus for Healthcare System Change

SPENDING ON HEALTH CARE ACCOUNTS FOR ~ 18% OF GDP IN THE U.S.1

HEALTH CARE COSTS ARE CONCENTRATED AMONG HEALTH CARE SYSTEM THOSE WITH MULTIPLE CHRONIC DISEASES2 $50

(‘1000s) $40 $30 COMPLEX EPISODIC $20 $10 $0 0 1-2 3-4 5+ Annual Cost per Person Number of Chronic Diseases FRAGMENTED WASTEFUL

Obesity, , , chronic kidney disease

1. Mitchell E. and Machlin S. Concentration of Health Expenditures and Selected Characteristics of High Spenders, U.S. Civilian Noninstitutionalized Population, 2015. Statistical Brief #506. AHRQ, 2017. 2. Cohen, SB. The concentration and Persistence in the Level of Health Expenditures for the U.S. Population, 2012-2013. Statistical Brief #481. AHRQ, 2015. CKD and ESRD Chronic and End-Stage Kidney Disease as Prime Model of the Burden of Chronic Illness: Cost: Quality of Life Economic 23% of Medicare budget (>$113 billion) The Burden of U.S. Kidney Disease 2002-2016 40,000,000 Americans – 96% not aware of their CKD

Age-Std CKD DALYs: DALY increase Vermont: 321 risk factors: Mississippi: 697 Metabolic (DM): (per 100,000) 93.8% Overall: +18.6% Dietary: 5.3% Death: +58.3% (Ages 20-54: 25.6% - CKD DM The Rogosin Institute

Diabetes and/or Hypertension are responsible for 60% of our end-stage renal patients requiring either dialysis or to continue to live: Obesity is linked to both Central Brooklyn Health Disparities

Significant differences in health outcomes between Brownsville and other parts of NYC Obesity

• More than 60% of Americans are overweight (including “obese”):

• Of all the developed economies, US has highest rate of obesity – 75% predicted by 2020

• Up to 400,000 U.S. deaths per year • Annual societal cost: $117 billion ($2.5

Prevalence of obesity highest in Americas and lowest in SE Asia Diabetes Facts:

•Worldwide, no. of diabetics has risen from 108 million in 1980 to 422 million in 2014. •Prevalence of diabetes among adults >18 over 18 has risen from 4.7% in 1980 to 8.5% in 2014. •Rising more rapidly in middle- and low-income countries. •Diabetes: major cause of blindness, , heart attacks, stroke and lower limb amputation.

WHO, 2017 Type 2 Diabetes in the U.S.A. Some Facts About Chronic Illness: Hypertension and Diabetes as Examples Hypertension: • Enormous global problem: 972 million in 2000; 1.56 billion by 2025 • China: Prevalence 27.8% of Chinese people (increases steeply with age); overall control 9.7% (Yichong et al, Intl J Cardiol, 2017) • U.S. 23.4% or 76.2 million people • 18% of global deaths; 162 million years of life lost U.S. Health Care

What, if anything, can we do about it? Where does health care happen?

Waldeck, 2019 The Rogosin Institute

Independent, Non-Profit (501c3) Clinical Care and Research Institute closely affiliated with The Kidney

Waste removal system; blood pressure control; red blood cell control

2 The Rogosin Institute

Normal End-Stage Diabetic Glomerulus Glomerulus The Rogosin Institute: 510 people serving NYC (110 Nurses)

• 11 dialysis units in NYC (2,000 ESRD patients) • Chronic Kidney Care • Clinical research • Kidney transplant program • Center for Health Action and Policy • Focus on prevention and wellness Achieving Better Health

The Centers for Disease Control and Prevention estimates that 80% of chronic Illness could be eliminated with attention to these four basic health factors: Better nutrition More physical activity Moderate to no alcohol use No tobacco A Too-Narrow View of Health: A multiplicity of factors – biological to societal: Making people WHOLE!!

Food Comorbidities Finances Age Environment/Culture Housing Spiritual Beliefs

Education Family PERSON

Depression

Transportation Psychological Factors Political Climate Healthcare System Stress Anxiety U.S. Centers for Disease Control (CDC) National Diabetes Prevention Program

What’s missing here?

The PEOPLE Who Can Fix the US Healthcare System?

Who can make us all healthier? YOU!!

The current statistics are unacceptable! We won’t take it anymore! You can be the ones to change the way things are and turn America around!!! Some Challenges

• Disparities – in health, SES, educational attainment, health “literacy” • Diverse health audiences to reach or accommodate • Stress – toxic stress, expenses (rent), dealing with dialysis • Transportation – rural vs. urban; few personal cars, subway inaccessibility • Housing – home dialysis limitations, non-functional elevators in city housing interferes with access to care • Food - healthy choices expensive, not always available We are going to do this right here in Central Brooklyn

NO EXCUSES !!!!! Nutrition in Obesity, Diabetes, Hypertension, Kidney Disease

Nutrition: Just how important is it?

How should we be thinking about it? The human body as a finely-tuned machine Matching the fuel to the engine requirements Mixing the Fuels

RECOMMENDED FUEL PORTIONS Carbohydrates Protein Fats

Meats - beef, Oils pork, lamb, Starches: breads, cereals, poultry, fish, Margarine grains, rice, pasta shellfish Animal fats - Dried beans, peas, lentils Eggs dairy, poultry fish, shellfish Fruits Cheese Nuts Vegetables - corn, peas, Tofu winter squash, lettuce, leafy greens

Milk, yogurt

Sugar, sweets, desserts

about 50% 25% 25% Read the Label The Importance of Nutrition Healthy Choices — “No Diet” FOOD as MEDICINE Health effects of dietary risks in 195 countries, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017 Lancet, April 3, 2019 In 2017, 11 million deaths and 255 DALYs were due to dietary risk factors: Key factors: • too much sodium (salt) • Low intake of whole grains • Low intake of fruits Physical Activity Physical Activity Recommendations Some examples Activity and Mortality The Importance of Physical Activty

Physical Activity No-to-light alcohol use No Smoking Rethinking Our Approach to “Health” Shifting from Medical/Nursing Care to Wellness Promotion • The failure of our present approach – medically and technology oriented; overly disease-focused; • Neglect of “public” health • Specific disease focus as opposed to wholistic, integrated approach to the human being A New Model

Integrated • education(school); good nutrition; activity • public health prevention • screening and early detection/intervention • treatment and prevention of progression • advanced compassionate care when necessary • Personal engagement at all times The Model

Wellness and QOL Continuity Across the Lifetime of Individuals and Families

Education Education Education Nutrition Nutrition, Activity Nutrition, Activity Nutrition, Activity Education Engagement Engagement Engagement Physical Screening Screening Screening activity Early intervention Intervention Advanced Treatment

0 20 30 40 50 60 70 80 90 100 Age The Rogosin Kidney Care Model It is never too late to make a difference!!! Central Brooklyn Health Movement The Place: Central Brooklyn

A movement of, by, and for the people!! A Proposed Solution: Central Brooklyn Health Movement (CBHM)

CBHM Fundamental Principle: The people with the problems are not the problem, rather they must be an ACTIVE part of the solution The People as Partners

Rogosin has over 25 years of experience in community outreach and mobilization utilizing the Problem Solving for Better Health® (PSBH®) methodology • Implemented in 32 countries • Over 60,000 participants, and 40,000 health promotion projects Problem Solving for Better Health®

PSBH® Methodology 1. Defining the problem 2. Prioritizing the problem 3. Defining a solution/ Asking the “Good Question” 4. Creating an action plan 5. Taking action

Participants apply PSBH® to solve local public and individual/family health problems Who Can Make Central Brooklyn Healthier? Who can successfully wage the war on DIABESITY? YOU!!

The current statistics are unacceptable! We won’t take it anymore! You can be the ones to change the way things are and turn Central Brooklyn (and America) around!!!